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PACIFIC GARDENS NURSING & REHA
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859253307
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Details
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CMS Inspection Results
The Center for Medicare & Medcaid Services (CMS) contracts with each state to conduct inspections once every 9-15 months to assure that certified facilities meet the minimum Medicare and Medicaid quality and performance standards.
- 08/22/2007 Health Survey for PACIFIC GARDENS NURSING & REHA
| Administration | ||
| Deficiency | Scope | Level of Harm |
| Train all employees on what to do in an emergency. | Isolated | Minimal harm or potential for actual harm |
| Keep accurate and appropriate medical records. | Isolated | Minimal harm or potential for actual harm |
| Get services outside the nursing home that meet professional standards. | Isolated | Minimal harm or potential for actual harm |
| post nurse staffing information. | Pattern | Potential for minimal harm |
| Environmental | ||
| Deficiency | Scope | Level of Harm |
| Make sure that the nursing home area is free of dangers that cause accidents. | Isolated | Minimal harm or potential for actual harm |
| Keep all essential equipment working safely. | Isolated | Minimal harm or potential for actual harm |
| Make sure there is a program to prevent/deal with mice, insects, or other pests. | Isolated | Minimal harm or potential for actual harm |
| Keep sound levels comfortable. | Pattern | Potential for minimal harm |
| Nutrition and Dietary | ||
| Deficiency | Scope | Level of Harm |
| Store, cook, and give out food in a safe and clean way. | Pattern | Minimal harm or potential for actual harm |
| Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. | Pattern | Minimal harm or potential for actual harm |
| Make sure that residents are well nourished. | Pattern | Minimal harm or potential for actual harm |
| 1) Provide 3 meals daily at regular times; or 2) serve breakfast within 14 hours after dinner; or 3) offer a snack at bedtime each day. | Pattern | Potential for minimal harm |
| Pharmacy Service | ||
| Deficiency | Scope | Level of Harm |
| 1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects. | Isolated | Minimal harm or potential for actual harm |
| Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly. | Isolated | Minimal harm or potential for actual harm |
| Properly mark drugs and other similar products. | Isolated | Minimal harm or potential for actual harm |
| Quality Care | ||
| Deficiency | Scope | Level of Harm |
| Give professional services that meet a professional standard of quality. | Pattern | Minimal harm or potential for actual harm |
| Make sure that residents receive treatment/services to continue to be able to care for themselves, unless a change is unavoidable. | Isolated | Minimal harm or potential for actual harm |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Isolated | Minimal harm or potential for actual harm |
| Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary. | Isolated | Minimal harm or potential for actual harm |
| Resident Rights | ||
| Deficiency | Scope | Level of Harm |
| Tell each resident who can get Medicaid benefits about 1) which items and services Medicaid covers and which the resident must pay for; or 2) how to apply for Medicaid, along with the names and addresses of State groups that can help. | Pattern | Potential for minimal harm |
- 08/21/2007 Fire Safety Survey for PACIFIC GARDENS NURSING & REHA
| Automatic Sprinkler Systems | ||
| Deficiency | Scope | Level of Harm |
| automatic sprinkler systems that have been maintained in working order. | Pattern | Minimal harm or potential for actual harm |
| Building Contruction | ||
| Deficiency | Scope | Level of Harm |
| approved construction type or materials. | Isolated | Minimal harm or potential for actual harm |
| Building Service Equipment | ||
| Deficiency | Scope | Level of Harm |
| heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Isolated | Minimal harm or potential for actual harm |
| Corridor Walls and Doors | ||
| Deficiency | Scope | Level of Harm |
| corridor and hallway doors that block smoke. | Isolated | Minimal harm or potential for actual harm |
| Electrical | ||
| Deficiency | Scope | Level of Harm |
| properly installed electrical wiring and equipment. | Widespread | Potential for minimal harm |
| Exits and Egress | ||
| Deficiency | Scope | Level of Harm |
| exits that are accessible at all times. | Isolated | Minimal harm or potential for actual harm |
| Fire Alarm Systems | ||
| Deficiency | Scope | Level of Harm |
| properly maintained smoke detectors. | Isolated | Minimal harm or potential for actual harm |
| an approved installation, maintenance and testing program for fire alarm systems. | Widespread | Potential for minimal harm |
| Hazardous Area | ||
| Deficiency | Scope | Level of Harm |
| construction that can resist fire for one hour or an approved fire extinguishing system. | Pattern | Minimal harm or potential for actual harm |
| Smoke Compartmentation and Control | ||
| Deficiency | Scope | Level of Harm |
| proper construction of ducts through walls designed to prevent smoke passage. | Widespread | Potential for minimal harm |
| Smoking Regulations | ||
| Deficiency | Scope | Level of Harm |
| posted No-smoking signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed. | Pattern | Potential for minimal harm |
- 10/03/2006 Fire Safety Survey for PACIFIC GARDENS NURSING & REHA
| Automatic Sprinkler Systems | ||
| Deficiency | Scope | Level of Harm |
| automatic sprinkler systems that have been maintained in working order. | Widespread | Potential for minimal harm |
| Building Service Equipment | ||
| Deficiency | Scope | Level of Harm |
| properly protected cooking facilities. | Pattern | Minimal harm or potential for actual harm |
| Fire Alarm Systems | ||
| Deficiency | Scope | Level of Harm |
| a fire alarm system that can be heard throughout the facility. | Isolated | Minimal harm or potential for actual harm |
| Hazardous Area | ||
| Deficiency | Scope | Level of Harm |
| construction that can resist fire for one hour or an approved fire extinguishing system. | Isolated | Minimal harm or potential for actual harm |
| Illumination and Emergency Power | ||
| Deficiency | Scope | Level of Harm |
| properly located and lighted Exit signs. | Isolated | Minimal harm or potential for actual harm |
| Miscellaneous | ||
| Deficiency | Scope | Level of Harm |
| fire safety features required by current fire safety codes. | Widespread | Potential for minimal harm |
- 09/06/2006 Health Survey for PACIFIC GARDENS NURSING & REHA
| Administration | ||
| Deficiency | Scope | Level of Harm |
| Keep accurate and appropriate medical records. | Pattern | Minimal harm or potential for actual harm |
| Follow all laws and professional standards. | Isolated | Minimal harm or potential for actual harm |
| Mistreatment | ||
| Deficiency | Scope | Level of Harm |
| Keep each resident free from physical restraints, unless needed for medical treatment. | Isolated | Minimal harm or potential for actual harm |
| Nutrition and Dietary | ||
| Deficiency | Scope | Level of Harm |
| Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. | Pattern | Potential for minimal harm |
| Pharmacy Service | ||
| Deficiency | Scope | Level of Harm |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Widespread | Immediate jeopardy to resident health or safety |
| Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly. | Widespread | Minimal harm or potential for actual harm |
| Make sure that residents are safe from serious medication errors. | Isolated | Minimal harm or potential for actual harm |
| 1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects. | Isolated | Minimal harm or potential for actual harm |
| Quality Care | ||
| Deficiency | Scope | Level of Harm |
| Give professional services that meet a professional standard of quality. | Pattern | Minimal harm or potential for actual harm |
| Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene. | Isolated | Minimal harm or potential for actual harm |
| Resident Assessment | ||
| Deficiency | Scope | Level of Harm |
| Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured. | Isolated | Minimal harm or potential for actual harm |
| Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them. | Isolated | Minimal harm or potential for actual harm |
| Do a new assessment after any major change in a resident's physical or mental health. | Isolated | Minimal harm or potential for actual harm |
| Resident Rights | ||
| Deficiency | Scope | Level of Harm |
| Make sure each resident has the right to choose activities, schedules and health care according to his or her interests, assessment, and plan of care. | Isolated | Minimal harm or potential for actual harm |
| Provide care in a way that keeps or builds each resident's dignity and self respect. | Isolated | Minimal harm or potential for actual harm |
| Immediately tell the resident, doctor, and a family member if: the resident is injured, there is a major change in resident's physical/mental health, there is a need to alter treatment significantly, or the resident must be transferred or discharged. | Isolated | Minimal harm or potential for actual harm |
- 10/04/2005 Fire Safety Survey for PACIFIC GARDENS NURSING & REHA
| Automatic Sprinkler Systems | ||
| Deficiency | Scope | Level of Harm |
| an approved automatic sprinkler system connected to the fire alarm system. | Pattern | Minimal harm or potential for actual harm |
| Building Contruction | ||
| Deficiency | Scope | Level of Harm |
| approved construction type or materials. | Isolated | Minimal harm or potential for actual harm |
| Electrical | ||
| Deficiency | Scope | Level of Harm |
| properly installed electrical wiring and equipment. | Isolated | Minimal harm or potential for actual harm |
| Emergency Plans and Fire Drills | ||
| Deficiency | Scope | Level of Harm |
| did not have a written emergency evacuation plan. | Isolated | Minimal harm or potential for actual harm |
| Fire Alarm Systems | ||
| Deficiency | Scope | Level of Harm |
| properly maintained smoke detectors. | Pattern | Minimal harm or potential for actual harm |
| Hazardous Area | ||
| Deficiency | Scope | Level of Harm |
| construction that can resist fire for one hour or an approved fire extinguishing system. | Pattern | Minimal harm or potential for actual harm |
| Medical Gases and Anesthetizing Areas | ||
| Deficiency | Scope | Level of Harm |
| proper medical gas storage and administration areas. | Isolated | Minimal harm or potential for actual harm |
| Smoking Regulations | ||
| Deficiency | Scope | Level of Harm |
| posted No-smoking signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed. | Pattern | Minimal harm or potential for actual harm |
- 08/25/2005 Health Survey for PACIFIC GARDENS NURSING & REHA
| Administration | ||
| Deficiency | Scope | Level of Harm |
| Train all employees on what to do in an emergency. | Pattern | Minimal harm or potential for actual harm |
| Environmental | ||
| Deficiency | Scope | Level of Harm |
| Make sure that staff members wash their hands when needed. | Isolated | Minimal harm or potential for actual harm |
| Nutrition and Dietary | ||
| Deficiency | Scope | Level of Harm |
| Hire enough skilled workers to carry out dietary service. | Pattern | Potential for minimal harm |
| Pharmacy Service | ||
| Deficiency | Scope | Level of Harm |
| 1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects. | Isolated | Minimal harm or potential for actual harm |
| At least once a month, have a licensed pharmacist check the drugs that each resident takes. | Isolated | Minimal harm or potential for actual harm |
| Properly mark drugs and other similar products. | Isolated | Minimal harm or potential for actual harm |
| Quality Care | ||
| Deficiency | Scope | Level of Harm |
| Give professional services that meet a professional standard of quality. | Pattern | Minimal harm or potential for actual harm |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Isolated | Minimal harm or potential for actual harm |
| Resident Rights | ||
| Deficiency | Scope | Level of Harm |
| Provide care in a way that keeps or builds each resident's dignity and self respect. | Isolated | Minimal harm or potential for actual harm |
| Immediately tell the resident, doctor, and a family member if: the resident is injured, there is a major change in resident's physical/mental health, there is a need to alter treatment significantly, or the resident must be transferred or discharged. | Isolated | Minimal harm or potential for actual harm |
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